“A sound mind in a sound body” is an ancient expression of the major elements of a good life, often cited as an argument for physical activity as a component of a well-rounded education. For the last several months, we have been examining basic elements of physical health: good nutrition and physical activity. This month, we will shift our focus to mental health – but as the ancients knew, physical and mental health are intertwined, and social factors, including our life experiences, can influence both aspects of well-being.

What is mental health?
The World Health Organization defines mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.” Mental illnesses can vary in severity, duration, and recurrence and can encompass conditions such as anxiety disorders, depression, post-traumatic stress disorder, and schizophrenia. Mental illness is relatively common in the United States; the Centers for Disease Control reports that in 2015, about one in five Americans 18 and older experienced a mental illness within the previous year, with about one in 25 Americans experiencing a serious mental illness (“a mental illness or disorder with serious functional impairment that substantially interferes with or limits one or more major life activities”).

“Behavioral health” is a term that is often used somewhat interchangeably with “mental health,” though it is a broader designation, often encompassing both mental health and related issues such as substance use. Substance use disorder is a topic worthy of its own column, and I plan to discuss it in more detail soon. A great resource for information on opioids is a series of blog posts by Angela Inglett on VACo’s 1207 to the 95 blog, and the Health and Human Resources Steering Committee will be hearing from several experts at our meeting on August 16.

How is Virginians’ mental health?
The Robert Wood Johnson Foundation includes mental health as a factor in its County Health Rankings, using self-reported measures of poor mental health (which may not always rise to the level of a diagnosed mental illness). Survey respondents are asked to provide the number of days out of the past 30 for which their mental health was not good, including “stress, depression, and problems with emotions.” In 2016, Virginia’s average number of poor mental health days was 3.5, with a range of 2.8-4.7 – slightly worse than the best-performing states, which report an estimated average of 3.1 poor mental health days. County-specific estimates of average numbers of poor mental health days are available at this link. The United Health Foundation’s America’s Health Rankings dis-aggregates 2016 survey responses by gender and income, among other factors, reporting that average numbers of poor mental health days are higher for females than for males (at both the state and national levels), and higher for those making $25,000 or less than for those earning higher incomes. The data breakdown is available at this link.

Another way of measuring mental health among Virginians is the percentage of adults reporting what the Robert Wood Johnson categorizes as “frequent mental distress,” or 14 or more days of poor mental health per month. These percentages varied by locality in 2016 from 9 to 16 percent, with an average of 11 percent. County-specific estimates are available at this link.

A worrisome national trend is an increase in suicide rates in almost every state between 1999 and 2016, according to the CDC. Virginia lost 1,166 residents to suicide in 2016, for a rate of 13.2 suicide deaths per 100,000 residents; although one suicide death is one too many, Virginia’s rate in 2016 was the 16th lowest rate among states. Although Virginia’s suicide rate was low relative to most other states, the fact that Virginia’s suicide rate increased by 17.4 percent between 1999 and 2016 is troubling.

What is Virginia doing to improve mental health?
Many efforts are underway to provide resources to Virginians struggling with poor mental health or mental illness. A major effort to enhance coverage for mental health treatment for individuals with certain serious mental illnesses, the Governor’s Access Plan, was launched in 2015 and has since been expanded by the General Assembly to cover more people; GAP provides limited mental health treatment benefits through Virginia’s Medicaid program to individuals who otherwise would not qualify for Medicaid benefits. A legislative committee, the Joint Subcommittee to Study Mental Health Services in the Commonwealth in the 21st Century, chaired by Senator Creigh Deeds, is in the midst of an extensive review of the overall structure of the state’s public mental health system, as well as ways to improve the interaction of people with mental illness with the justice system. A summary of recommendations from the Joint Subcommittee that have been enacted through statutory changes or budget provisions is available at http://dls.virginia.gov/groups/mhs/recommendation050718.pdf.

One of the major changes to the public system to emerge from the Joint Subcommittee is the STEP-Virginia plan, which was enacted in 2017 and will require, when fully phased in, a standard array of services to be provided at each Community Services Board (CSB). The first step in this plan, same-day access to mental health assessments, was partially funded in FY 2018 and fully phased-in in the recently-passed biennium budget, which also funds the second step, primary care screenings (due to the frequency with which other medical issues co-occur with mental illness), and begins to fund the next steps (outpatient substance abuse and detoxification services) in FY 2020. Localities are funding partners with the state in supporting CSBs; generally, state funding for CSBs is not to exceed 90 percent of a CSB’s total funding, and localities supply the balance, though some localities contribute far in excess of these amounts and some localities receive waivers from the requirement due to financial hardship.

Adverse Childhood Experiences and Mental Health
Mental illness can be caused by many factors, including chemical imbalances in the brain and genetic factors. An area of significant research interest in recent years is the effect of trauma on health outcomes later in life, especially the effect of Adverse Childhood Experiences (ACEs). An important study in 1998 examined the relationship between certain traumatic experiences in childhood, such as psychological or sexual abuse, substance abuse in the home, or violence directed toward a mother or stepmother, and found that “the impact of these adverse childhood experiences on adult health status is strong and cumulative.” The exact ways in which childhood trauma affects later-life outcomes is still the subject of research. The researchers in the 1998 ACEs study theorized that the connection between the traumatic experiences in childhood and poor health outcomes in adulthood, such as depression, substance abuse, heart disease, cancer, and obesity, may be related to the ways in which people self-medicated the anxiety and depression that resulted from their childhood trauma, such as by smoking or abusing alcohol. A recent study conducted by researchers at the University of Wisconsin-Madison found that high levels of childhood stress actually influenced how certain genes were expressed, including genes that affect mood, and that this change persisted later in life. In an article about the study, Reid Alisch, one of the researchers, said, “What we’re finding is that after 10 years or so there are still markers, like fossils in our genome, telling us there was a trauma here. And that trauma may make this individual more susceptible to a second trauma, or even worse, a behavioral change, later in life.”
Research suggests that adverse childhood experiences are common in the United States. A research brief produced by Child Trends from data compiled in the 2016 National Survey of Children’s Health found that 24 percent of children nationwide had experienced at least one adverse childhood experience. This study reported that 22 percent of children in Virginia had experienced at least one adverse childhood experience, 8 percent had experienced two, and 11 percent had experienced three or more. Virginia Department of Health recently added a module on ACEs to its behavioral health survey, so more detailed data on ACEs in Virginia’s population should be available in future years.

Although childhood trauma can have serious and long-lasting effects, research has found that our fates are not sealed by what happens in childhood. The Child Trends report notes that a positive relationship with even one adult can help buffer the effects of trauma, and that resilience can be built by learning coping techniques. Trauma-informed care has become an important aspect of mental health, and language in the biennium budget directs Virginia’s Secretary of Health and Human Resources to convene a workgroup to develop a trauma-informed system of care throughout the agencies within the Secretariat and explore opportunities to expand trauma-informed care statewide.

In my next column, I’ll be highlighting some of the approaches Virginia counties have taken to address the critical issue of mental health.